UNIT 1 RESPIRATORY FLASHCARDS
(374 cards)
1
Q
Which muscles tense
A
CricoThyroid: ‘Cords Tense’
2
Q
Which muscles relax the vocal cords?
A
ThyroaRytenoid: ‘They Relax’
3
Q
Which muscles abduct
A
Abduct and Adduct:
Posterior CricoArytenoid: ‘Please Come Apart’ (or take out back)
4
Q
Which muscles adduct the vocal cords?
A
Lateral CricoArytenoid: ‘Let’s Close Airway’
5
Q
Describe the sensory innervation of the upper airway.
What are the nerves?
A
Trigeminal
Glossopharyngeal
Superior Laryngeal Nerve
Recurrent Laryngeal Nerve
6
Q
What are the branches of the Trigeminal nerve
A
V1 (ophthalmic)
V2 (Maxillary)
V3 (mandibular)
7
Q
V1 of trigeminal nerve innervates
A
Nares & anterior 1/3 of septum
8
Q
V2 (maxillary) innervates =
A
Turbinates & septum
9
Q
Innervates Anterior 2/3 of tongue
A
Trigeminal V3 mandibular
10
Q
What nerve innervates the turbinates and septum?
A
V2 maxillary
11
Q
Posterior 1/3 of tongue innervated by
A
Glossopharyngeal nerve
12
Q
Soft palate innervated by
A
Glossopharyngeal nerve
13
Q
Oropharynx innervated by
A
Glossopharyngeal nerve
14
Q
Vallecula innervated by
A
Glossopharyngeal nerve
15
Q
Anterior side of epiglottis innervated by
A
Glossopharyngeal nerve
16
Q
Superior laryngeal : Internal branch innervates where
A
posterior side of epiglottis → to level of vocal cords
17
Q
External branch of SLN =
A
0 sensory function (motor innervation to cricothyroid muscle)
18
Q
Recurrent laryngeal innervates
A
Below the vocal cords → trachea
19
Q
How does recurrent laryngeal nerve injury affect the integrity of the airway?
A
Bilateral:
Acute = Respiratory distress (unopposed action of cricothyroid muscles)
20
Q
Acute injury to Bilateral RLN leads to
A
Acute respiratory distress because of unopposed action of the CRICOTHYROID MUSCLES
21
Q
Unilateral RLN injury leads to
A
No respiratory distress
22
Q
How does superior laryngeal nerve injury affect the integrity of the airway? Bilateral and unilateral
A
Bilateral: Hoarseness / No respiratory distress
Unilateral: No respiratory distress
23
Q
Chronic RLN injury leads to
A
No respiratory distress
24
Q
Landmark for the Glossopharyngeal nerve block:
A
Palatoglossal arch at the anterior tonsillar pillar
25
Landmark for the Superior laryngeal nerve block:
Greater cornu of hyoid
26
Landmark for the Transtracheal nerve block:
Cricothyroid membrane
27
The adult larynx extends from.
C3 – C6
28
Composition of the larynx, (bone, ligaments and cartilages)
It consists of bone, ligaments, and 9 cartilages (3 paired & 3 unpaired).
29
Anterior ligaments of the larynx
Thyrohyoid
Cricothyroid
30
The 3 unpaired cartilages of the airway
Epiglottis
Thyroid
Cricoid
31
2 Significant consequences of laryngospasm include
hypoxia and negative-pressure pulmonary edema.
32
Treatment of Laryngospasm
100% FiO2
Remove noxious stimulation
Deepen anesthesia
CPAP 15 - 20 cm H2O
Open the airway (head extension, chin lift)
Larson’s maneuver
Succinylcholine
33
Regarding succinylcholine for laryngospasm infants and small children. What route is the fastest?
Infants and small children should receive atropine 0.02 mg/kg with succinylcholine.If no IV access, submental administration will produce the fastest onset
34
If no IV access and the patient can’t have succinylcholine, then what is the only NMB that can be given IM
Rocuronium is the only other NMB that can be given IM.
35
Contraction of the inspiratory muscles does what to thoracic pressure and thoracic volume? This is an examples of which law?
Contraction of the inspiratory muscles reduces thoracic pressure and increases thoracic volume. This is an example of Boyle's law.
36
Inspiration: Muscles at play
Accessory muscles include the sternocleidomastoid and scalene muscles.
The diaphragm and external intercostals contract during inspiration (tidal breathing).
37
During inspiration , The diaphragm increases the_____While the external intercostals increase
superior-inferior dimension of the chest; the anterior-posterior diameter.
38
Exhalation: passive or active? driven by what process
Exhalation is usually passive; this process is driven by the recoil of the chest wall.
39
Active exhalation is carried out by the abdominal musculature which include
Rectus abdominis
Internal obliques
Transverse abdominis
External obliques).
40
Muscles that serve a secondary role in active exhalation
The internal intercostals
41
Exhalation becomes an active process when and what patients population?
minute ventilation increases or in patients with lung disease, such as COPD.
42
A forced exhalation is required to
cough and clear the airway of secretions.
43
What is the difference between minute ventilation and alveolar ventilation?
Minute ventilation (Ve) is the amount of air in a single breath multiplied by the number of breaths per minute.
Ve = Vt x RR
Alveolar ventilation (VA) only measures the fraction of Ve that is available for gas exchange. Said another way, it removes anatomic dead space gas from the minute ventilation equation.
44
Ve =
Vt x RR
45
VA and CO2 production
is directly proportional to CO2 production
46
VA and PaCO2 production
VA is indirectly proportional to PaCO2
47
VA=
(Vt - Anatomic dead space) x RR
48
Define the 4 types of dead space.
Anatomic Vd:
Alveolar Vd:
Physiologic Vd:
Apparatus Vd:
49
Anatomic dead space (Vd) is defined as air
Air confined to the conducting airways
50
Alveolar dead space is defined as
Alveoli that are ventilated but not perfused
51
Physiologic dead space is defined as
Anatomic Vd + Alveolar Vd
52
Apparatus dead space is
Vd added by equipment
53
Examples of anatomic deadspace
Nose/mouth → terminal bronchioles
54
Examples of Alveolar Vd:
Reduced pulmonary blood flow (↓ CO)
55
Examples of Physiologic Vd:
Anything that increases anatomic or alveolar Vd
56
Examples of Apparatus Vd:
Facemask, HME, limb of circle system if incompetent valve present
57
What does the alveolar compliance curve tell you?
Alveolar ventilation is a function of alveolar size and its position on the alveolar compliance curve.
58
The best ventilated alveoli are the
most compliant (steep slope of the curve).
59
The poorest ventilated alveoli are the
least compliant (flat portion of the curve).
60
What is the formula for compliance?
Change in volume/Change in pressure
61
Perfusion is greatest where and why?
Perfusion is greatest at the base of the lung due to gravity
62
Ventilation is greatest where and why?
Ventilation is greatest at the lung base due to HIGHER ALVEOLAR COMPLIANCE
63
Alveolar compliance curve: The curve plots on y-axis; x-axis, :
ALveolar volume, Transpulmonary pressure
64
What does the V/Q ratio represent?
The V/Q ratio is the ratio of ventilation to perfusion (minute ventilation / cardiac output).
65
Normal minute ventilation =
4 L/min
66
Normal cardiac output =
5 L/min
67
Normal V/Q ratio =
0.8
68
Why is normal V/Q ratio=
Ve/CO= 4/5 = 0.8
69
Dead space and shunt are
absolutes.
70
Dead space: V/Q =
infinity (10/0 = infinity)
71
Shunt: V/Q =
0 (0/10 = 0)
72
For V/Q , If the number is larger than 0.8, then this moves towards
dead space.
73
For V/Q ,If the number is smaller than 0.8, then this moves towards
shunt.
74
West Zone Lung I
Comment on ventilation without perfusion
Zone I
PA > Pa > Pv
Dead space
Ventilation without perfusion
75
West Zone Lung II
Zone II
Pa > PA > Pv
Waterfall
Normal physiology
76
Which lungs is normal perfusion
Zone II
77
Zone III West Zone lung
Pa > Pv > PA
Shunt
Perfusion without ventilation
78
Zone IV West zone
Pa > Pist > Pv > PA
Pressure in the interstitial space impairs ventilation and perfusion
79
Perfusion follows what type of pattern
Central to peripheral pattern, is affected by gravity
80
Recite the alveolar gas equation.
PAO2 = FiO2 x (Pb - PH2O) - (PaCO2 / RQ)
Pb = Atmospheric pressure
PH2O = 47 mmHg
RQ = Respiratory quotient = 0.8
81
What are 2 things that The alveolar gas equation tells us?
tells us that hypoventilation can cause hypercarbia and hypoxemia. It also explains how supplemental oxygen reverses hypoxemia, but it does nothing to reverse hypercarbia.
82
Respiratory Quotient is calculated by
RQ= (CO2 elimination / O2 consumption) = (200 mL / 250 mL)
83
Alveolar oxygen in the healthy adult patient breathing room air at sea level is ~
105.98 mmHg.
84
What is the A-a gradient,
The A-a gradient is the difference between alveolar oxygen (PAO2) and arterial oxygen (PaO2).
85
What does the A-a gradient help diagnose?
It helps us diagnose the cause of hypoxemia by quantifying the amount of venous admixture.
86
A-a gradient normal
It is normally 5 - 15 mmHg.
87
Factors affecting A-a gradient?
It is increased by high FiO2, aging, vasodilators, right-to-left shunting, and diffusion limitation.
88
List the 5 causes of hypoxemia. Which ones are reversed with supplemental oxygen?
Reduced FiO2- reverse by O2
Hypoventilation- reverse by O2
Diffusion limitation- reverse by O2
V/Q mismatch - reverse by O2
Shunt (NOT FIXABLE WITH O2)
89
Why can't you fix SHUNTING with supplemental O2?
Because there is no way O2 to access pulmonary capillary. All the other causes allow O2 to transfer between the alveolus and the pulmonary capillary
90
Normal TV
500ml
91
Inspiratory Reserve volume is
3000 ml
92
Residual volume is
1200 ml
93
Define Closing volume
It is the volume above the residual volume where the small airways begin to close.
94
What is the volume that cannot be exhaled from the lungs?
Residual volume
95
What is the amount of air that can be FORCIBLY INHALED after a tidal inhalation?
Inspiratory Reserve volume
96
Volume of gas that remains in the lung after complete exhalation
Inspiratory reserve volume
97
Volume that enters and exits the lungs with tidal breathing is the _____Volume
Tidal volume; 500ml
98
Total lung capacity is addition of
IRV + TV + ERV + RV
99
Normal TLC range
5800ml
100
Vital Capacity Formula + Normal range
IRV+ TV+ ERV ; 4500
101
Inspiratory Capacity Formula + normal range
IRV + TV; 3500
102
Functional Residual Capacity Formula + Normal range
ERV + RV; 2300
103
Closing Capacity formula + normal range
RV + CV; Variable
104
Why cant FRC be measured by conventional spirometry?
Because it contains RV, the FRC can’t be measured by conventional spirometry.
105
Conditions that reduce FRC have several things in common. They tend to
reduce outward lung expansion and or reduce lung compliance.
106
When FRC is reduced what occurs?
intrapulmonary shunt (zone III) increases. PEEP acts to restore FRC by reducing zone III.
107
What conditions increase FRC?
COPD or any condition that causes air trapping increases FRC.
108
What tests can measure FRC?
FRC is measured indirectly by
nitrogen washout
helium wash in
Body plethysmography.
109
What is closing volume, and what increases it?
Closing volume is the point at which dynamic compression of the airways begins. Said another way, it’s the volume above residual volume where the small airways begin to close during expiration.
110
Name things that INCREASE CLOSING VOLUME?
mnemonic: CLOSE-P
COPD
Left ventricular failure
Obesity
Supine position
Extreme age
Pregnancy
111
State the equation and normal value for oxygen carrying capacity.
O2 Carrying Capacity (CaO2)
112
CaO2 is how much
How much O2 is carried in the blood
113
CaO2 formula
CaO2 = (1.34 x Hgb x SaO2) + (PaO2 x 0.003)
114
Normal CaCO2
Normal = 20 mL O2/dL
115
State the equation and normal value for oxygen delivery.
Oxygen Delivery (DO2)
116
DO2 is How much
O2 is delivered to the tissues
117
Normal DO2 is
Normal = 1,000 mL O2/min
118
DO2 formula
DO2 = CaO2 x Cardiac output x 10
119
Discuss the factors that alter the oxyhemoglobin dissociation curve.: LEFT SHIFT
Decreased Temperature
Decreased CO2
Decrease H+ {(Increase pH)}
Decreased 2, 3 DPG
HgbMet
HgbCO
HgbF
120
Right shift and affinity for oxygen
Decrease affinity for Oxygen (R -Release)
121
Left shift and affinity for oxygen
Increase affinity for Oxygen (L-LOVE)
122
Discuss the factors that alter the oxyhemoglobin dissociation curve.: RIGHT SHIFT
CADET face RIGHT
Increased CO2
Acidosis (Decreased pH, increased H+)
Increased 2,3, DPG
Exercise
Increased temperature
123
P50 is
P50 is the oxygen tension at which hemoglobin is 50% saturated which is typically around 26 mm Hg and is a measure of hemoglobin’s affinity for oxygen.
50% saturation on Y-axis
26.5 mmHg partial pressure on X-axis
124
Left shift occurs in the
Lungs
125
Right shift occurs in the
Metabolically active tissue
126
How is carbon dioxide transported in the blood?
Carbon dioxide is the primary by-product of aerobic metabolism. Venous blood transports it to the lungs, where it’s excreted into the atmosphere.
127
Mechanisms of CO2 Transport: my 70-30 rule
BiHP
Bicarbonate = 70%
Bound to hemoglobin = 23%
Dissolved in the plasma = 7%
128
Most of the CO2 is transported in the form of
bicarbonate
129
The reaction that converts CO2 to HCO3- requires the enzyme.
carbonic anhydrase
130
When the RBC releases HCO3- into the plasma, what happens?
Cl- is transported into the RBC to maintain electroneutrality. This is called the Hamburger shift (chloride shift).
131
Equation for the bicarbonate formaiton
H2O + CO2 H2CO3 H+ + HCO3-
132
Carbonic anhydrase catalyze
Water + CO2 to CarBonic acid
133
Describe the Bohr effect. (think BOX)
The Bohr effect describes O2 carriage. It says that ↑ CO2 and ↓ pH cause the erythrocyte to release O2.
Conceptually, it’s the cell’s way of asking hemoglobin to release oxygen to support aerobic metabolism.
134
Describe the Haldane effect.
The Haldane describes CO2 carriage.
It says that ↑ O2 causes the erythrocyte to release CO2 (occurs in the lungs). Said another way, the Haldane effect states that deoxygenated Hgb is able to carry more CO2 (occurs in venous blood).
135
List the 3 primary causes of hypercapnia, and provide examples of each.
Increase CO2 production
Decreased CO2 elimination
Rebreathing
136
Sepsis and Co2 production
Increase
137
MH and CO2 production
Increase
138
Overfeeding and CO2 production
Increase
139
Prolonged seizure and CO2 production
Increase
140
Thyroid storm (Hyperthyroidism) and CO2 production
Increase
141
Burns and CO2 production?
Increase
142
Decrease CO2 elimination cause"?
Airway obstruction
Increased Dead space
143
Increase Dead space and CO2 elimination
Decrease
144
Airway obstruction and CO2 elimination
Decrease
145
Increase Vd/Vt and CO2 elimination
Decrease
146
ARDS and CO2 elimination
decrease
147
COPD and CO2 elimination
Decrease
148
Respiratory center and CO2 elimination
Decrease
149
Drugs overdose and CO2 elimination
Decrease
150
Inadequate NMB and CO2 elimination
Decrease
151
2 examples of when rebreathing occurs
Incompetent one way valve
Exhausted soda lime.
152
The respiratory center resides in the
brainstem (reticular activating system).
153
2 types of respiratory centers:
Medullary Respiratory centers
154
2 types of respiratory centers:
Medullary Respiratory centers
155
What inhibits the DORSAL RESP CENTER
Pneumotaxic center
156
What stimulates the DORSAL RESP CENTER
Apneustic center
157
Contrast the location and function of the central and peripheral chemoreceptors.
Central Chemoreceptor:
Located in the medulla
Responds to the H+ concentration in the CSF
The H+ in the CSF is a function of the PaCO2 of the blood (remember, the PaCO2 is the primary stimulus to breathe)
Peripheral Chemoreceptors:
Located in the carotid bodies: Nerves of Hering → Glossopharyngeal n. (CN IX)
Located in the aortic arch: Vagus n. (CN X)
They respond to ↓O2, ↑CO2, and ↑H+
158
Central chemoreceptors are located in the
Medulla
159
Central chemoreceptors responds to
H+ concentration in the CSF
160
Central chemoreceptors Responds to the H+ concentration in the CSF and The H+ in the CSF is a function of the
PaCO2 of the blood (remember, the PaCO2 is the primary stimulus to breathe)
161
Contrast the location and function of the central and peripheral chemoreceptors.
Central Chemoreceptor: Medulla)
Peripheral Chemoreceptors:
Located in the carotid bodies: Nerves of Hering → Glossopharyngeal n. (CN IX)
Located in the aortic arch: Vagus n. (CN X)
They respond to ↓O2, ↑CO2, and ↑H+
162
Central chemoreceptors responds to (CC)
CO2 and H+ concentration in the CSF
163
Peripheral Chemoreceptors are Located in the
carotid bodies: Nerves of Hering → Glossopharyngeal n. (CN IX)
164
Peripheral Chemoreceptors: respond to
They respond to ↓O2, ↑CO2, and ↑H+
165
Peripheral Chemoreceptors are Located in the
carotid bodies: Nerves of Hering → Glossopharyngeal n. (CN IX)
Located in the aortic arch: Vagus n. (CN X)
166
Which reflex prevents overinflation of the lungs?
Hering-Breuer inflation reflex
167
Which reflex prevents overinflation of the lungs?
Hering-Breuer inflation reflex
168
What is hypoxic pulmonary vasoconstriction?
Hypoxic pulmonary vasoconstriction minimizes shunt by reducing blood flow through poorly ventilated alveoli (think atelectasis or OLV).
169
What activates HPV?
A low alveolar PO2 (not arterial PO2) is the trigger that activates HPV. The effect begins almost immediately and reaches its full effect after 15 min.
170
What things impair HPV, and what is the consequence of this?
Anything that inhibits HPV increases shunt (perfusion without ventilation). s
IV anesthetics do NOT inhibit HPV.
171
Examples of things that impairs HPV include
Halogenated anesthetics > 1-1.5 MAC
Phosphodiesterase inhibitors
Dobutamine
Vasodilator
172
Do NOT inhibit HPV.
IV anesthetics
173
What does the diffusing capacity for carbon monoxide tell us?
The diffusing capacity for carbon monoxide (DLCO) is used to assess how well the lung can exchange gas.
174
Normal diffusing capacity for CO?
Normal = 17 - 25 mL/CO/min/mmHg
175
Using Fick’s law of diffusion, the DLCO tells us 2 key characteristics about the alveolar-capillary interface:
Surface area (↓ by emphysema)
Thickness (↑ by pulmonary fibrosis and pulmonary edema)
176
Therefore, DLCO is reduced by anything that
reduces alveolar surface area and/or increases the thickness of the alveolar-capillary interface.
177
Using Fick’s law of diffusion, the DLCO tells us 2 key characteristics about the alveolar-capillary interface:
Surface area (↓ by emphysema)
Thickness (↑ by pulmonary fibrosis and pulmonary edema)
178
How is tobacco smoke harmful?
Smoking increases SNS tone, sputum production, carboxyhemoglobin concentration, and the risk of infection.
179
Describe the short and intermediate term benefits of smoking cessation.
Short term cessation does NOT reduce the risk of postoperative pulmonary complications, but short term benefits include: SNS stimulating effects of nicotine dissipate after 20 – 30 minutes
P50 returns to near normal in 12 hours (CaO2 improves)
180
Intermediate term effects of smoking cessation: The return of normal pulmonary function requires at least
6 weeks.
181
Cigarette smoking-> Hepatic enzyme induction subsides after
6 weeks.
182
Intermediate term effects of smoking cessation: The return of normal pulmonary function requires at least
6 weeks and those good effects include
Airway function
Mucociliary clearance
Sputum production
Pulmonary immune function
183
Compare and contrast pulmonary function tests in obstructive vs restrictive lung disease.
FEV1/FVC ratio
Very Decreased in Obstructive
NORMAL is restrictive
184
Compare and contrast pulmonary function tests in obstructive vs restrictive lung disease.FEF 25-75%
Very Decreased in Obstructive
NORMAL is restrictive
185
Compare and contrast pulmonary function tests in obstructive vs restrictive lung disease. RV
Normal to increase in obstructive
Decrease in restrictive
186
Compare and contrast pulmonary function tests in obstructive vs restrictive lung disease.TCL
Normal to increase in obstructive (if gas trapping)
Decrease in restrictive
187
Compare and contrast pulmonary function tests in obstructive vs restrictive lung disease.FRV
Normal to increase in obstructive (if gas trapping)
Decrease in restrictive
188
Compare and contrast pulmonary function tests in obstructive vs restrictive lung disease.FEV1
Normal to decrease
DECREASE In RESTRICTIVE
189
Compare and contrast pulmonary function tests in obstructive vs restrictive lung disease.FVC
Normal to decrease
DECREASE In RESTRICTIVE
190
Discuss the following pulmonary flow-volume loops: normal, obstructive, restrictive, and fixed obstruction.
Normal: Upside down ice cream cone
Obstructive: Normal inspiration with expiratory obstruction.
Restrictive: Shape is similar to normal loop, but the restrictive loop is smaller and right shifted.
Fixed Obstruction: Inspiration and expiration are affected.
191
An extrathoracic obstruction is
abnormal during inspiration and normal during expiration.
192
An intrathoracic obstruction is
normal during inspiration and abnormal during expiration.
193
Give an example of a disease that produces the following pulmonary flow-volume loops: obstructive, restrictive, and fixed obstruction.
Obstructive: COPD
Restrictive: Pulmonary fibrosis
Fixed Obstruction: Tracheal stenosis
194
What is the treatment for acute bronchospasm?
100% FiO2
Deepen anesthetic (volatile agent, propofol, lidocaine, ketamine)
Inhaled beta-2 agonist (albuterol)
Inhaled anticholinergic (ipratropium)
Epinephrine 1 mcg/kg IV
Hydrocortisone 2-4 mg/kg IV (takes several hours to take effect)
Aminophylline
Helium-oxygen (Heliox) reduces airway resistance (↓'s Reynold’s number
195
Not used in the treatment of acute bronchospasm
*Montelukast
196
What is alpha-1 antitrypsin deficiency?
Alveolar elastase is a naturally occurring enzyme that breaks down pulmonary connective tissue. This enzyme is kept in check by alpha-1 antitrypsin (produced in the liver). When there's a deficiency of alpha-1 antitrypsin, alveolar elastase is free to wreak havoc on pulmonary connective tissue. This ultimately leads to panlobular emphysema.
197
What is the definitive treatment for alpha-1 antitrypsin deficiency.
Liver transplant i
198
Describe the goals and strategies for mechanical ventilation in the patient with COPD.
The goal is to prevent barotrauma and reduce air trapping. T
199
Describe the goals and strategies for mechanical ventilation in the patient with COPD. This is accomplished by:
Low tidal volume (6-8 mL/kg IBW)
Increased expiratory time to minimize air trapping
Slow inspiratory flow rate optimizes V/Q matching
Low levels of PEEP are ok, so long as air trapping does not occur
200
Restrictive lung disease is characterized by:
Impaired lung expansion
Decreased lung volumes
Normal pulmonary flow rates
201
What do intrinsic lung diseases affect?
Intrinsic Lung Disease (affects lung parenchyma):
202
Give examples of Intrinsic Lung Disease (affects lung parenchyma): acute
Acute: aspiration, negative pressure pulmonary edema
203
Give examples of Intrinsic Lung Disease (affects lung parenchyma): Chronic
Chronic: pulmonary fibrosis, sarcoidosis
204
What do extrinsic lung diseases affect?
Extrinsic Lung Disease affects areas around the lungs
205
Chest wall / mediastinum lung disease
kyphoscoliosis, flail chest, neuromuscular disorders, mediastinal mass
206
Increased intraabdominal pressure: pregnancy, obesity, ascites
pregnancy, obesity, ascites
207
List the risk factors for aspiration pneumonitis OTHER than GI issues
Trauma
Cricoid pressure
Impaired airway reflexes
Emergency
Pregnancy
208
GI risk factors for aspiration pneumonitis
GERD
GI Obstruction
Peptic ulcer disease
Ascites
Hiatal hernia
209
Describe the pharmacologic prophylaxis of aspiration pneumonitis.
Antacids, PPI, H2 antagonists, GI stimulants, Antiemetics,
210
Mendelson's syndrome is a.
chemical aspiration pneumonitis that was first described in OB patients receiving inhalation anesthesia
211
Risk factors include Mendelson's syndrome
Gastric pH < 2.5
Gastric volume > 25 mL (0.4 mL/kg)
212
Describe the treatment of aspiration.FIRST STEP
Tilt the head downward or to the side (first action).
Upper airway suction to remove particulate matter.
Lower airway suction is only useful for removing particulate matter. It doesn't help the chemical burn from gastric acid.
Secure the airway to support oxygenation.
PEEP to reduce shunt.
Bronchodilators to reduce wheezing.
Lidocaine to reduce the neutrophil response.
Steroids probably don't help.
Antibiotics are only indicated if the patient develops a fever or an increased WBC count > 48 hours
213
Lower airway suction is only useful for
removing particulate matter. It doesn't help the chemical burn from gastric acid
214
Flail chest is a consequence of The key characteristic is paradoxical movement of the chest wall at the site of the fractures.
blunt chest trauma with multiple rib fractures.
215
The key characteristic of flail chest?
Paradoxical movement of the chest wall at the site of the fractures. Flail chest: The injured ribs move outward & affected region doesn't empty.
216
Normal respiratory movement vs flail chest
The chest wall moves inward & lungs empty.
217
Treatment of flail chest?
epidural catheter or intercostal nerve blocks (higher risk of LA toxicity).
218
Inspiration (Negative Intrathoracic Pressure)
Normal: The chest wall moves outward & lungs expand.
Flail chest: The injured ribs move inward & collapses affected region
219
Expiration (Positive Intrathoracic Pressure)
Normal: The chest wall moves inward & lungs empty.
Flail chest: The injured ribs move outward & affected region doesn't empty.
220
Define pulmonary hypertension, a
Pulmonary hypertension is defined as a mean PAP > 25 mmHg
221
Discuss the goals of anesthetic management for pulmonary HTN
Goals: Optimize PVR
222
Pulmonary HTN Causes:
COPD, left-sided heart disease, connective tissue disorders
223
Drugs that increase PVR
Nitrous
Ketamine
Desflurane
224
Drugs that increased intrathoracic pressure
PEEP
Atelectasis
Mechanical ventilation
225
Decreased PVR
Increased Pao2
Hypocarbia
Alkalosis
226
Few things that decreased intrathoracic pressure
Preventing coughing/straining
Normal lung volumes
Spontaneous ventilation
High frequency jet ventilation
227
Drugs that decrease PVR
Inhaled nitric oxide
Nitroglycerin
Phosphodiesterase inhibitors (Sildenafil)\
Prostaglandins
CCBs
ACEI
228
The patient with cor pulmonale (right-heart failure) is also sensitive to
increased PVR
229
Discuss the pathophysiology of carbon monoxide poisoning.
Carbon monoxide reduces the oxygen carrying capacity of blood (left shift)
230
CO binds to the O2 bindings site on Hgb
It binds to the oxygen binding site on hemoglobin with an affinity 200x that of oxygen.
231
CO Impaired what 2 processes.
Oxidative phosphorylation is impaired and metabolic acidosis results.
232
If soda lime is desiccated, then volatile anesthetics can produce
CO (Des > Iso >>> Sevo)
233
Produce the most CO from soda lime dessication
DES
234
Produce the least CO from soda lime dessication
SEVO
235
CO is measured with a
co-oximeter (not pulse oximeter). Patients take on a cherry red appearance (not cyanosis)SNS stimulation may be confused with light anesthesia or pain
236
Discuss the treatment of carbon monoxide poisoning.
100% FiO2 until CoHgb is less than 5% or for 6 hours
Hyperbaric oxygen if CoHgb >25% or the patient is symptomatic
237
List the absolute indicatioms of One-lung Ventilation?
Isolation of one lung to avoid contamination infection, massive hemorrhage
238
Unilateral bronchopulmonary lavage, what is an absolute needs?
One lung ventilation
239
Bronchopleural fistula, requires Absolute indications for
One lung ventilation
240
Large unilateral lung cyst or bulla Absolute indications for
One lung ventilation
241
Life threatening hypoxemia r/ to lung disease Absolute indications for
One lung ventilation
242
Discuss how anesthesia in the lateral decubitus position affects the V/Q relationship.
Nondependent lung:
Moves from flatter region (less compliant) to an area of better compliance (slope).
Ventilation is optimal in this lung.
243
Discuss how anesthesia in the lateral decubitus position affects the V/Q relationship--> Dependent lung:
Moves from the slope to the lower, flatter area of the curve (less compliant).
Perfusion is best in this lung (effect of gravity).
A reduction of alveolar volume contributes to atelectasis.
The net effect is that ventilation is better in the nondependent lung and perfusion is better in the dependent lung. This creates V/Q mismatch and increases the risk of hypoxemia during OLV.
244
Net effect on OLV
The net effect is that ventilation is better in the nondependent lung and perfusion is better in the dependent lung. This creates V/Q mismatch and increases the risk of hypoxemia during OLV.
245
Discuss the management of hypoxemia during one-lung ventilation.
100% FiO2
Confirm DLT position with bronchoscope (poor position is the most common DLT complication)
CPAP 10 cm H2O to non-dependent (non-ventilated) lung
PEEP 5 - 10 cm H2O to dependent (ventilated) lung
Alveolar recruitment maneuver
Clamp pulmonary artery to the non-dependent (non-ventilated) lung
Resume two-lung ventilation
*If hypoxemia is severe, then it’s prudent to resume two lung ventilation promptly.
246
What is mediastinoscopy, and why is it performed?
Mediastinoscopy is performed to obtain biopsy of the paratracheal lymph nodes at the level of the carina. This helps the surgeon stage the tumor prior to lung resection.
247
What is the MOST COMMON potential complications of mediastinoscopy?
Hemorrahge
248
What is the most 2nd common complication of mediastnoscopy?
Pneumothorax
249
Other complication of mediastinoscopy?
Impaired cerebral perfusion
Dysrhythmias
Air embolism
Chylothorax
Hoarseness/ vocal cord paralysis
250
Innominate artery compression compromises
the circulation to the right upper extremity and the right side of the circle of Willis.Place an a-line or pulse oximeter on the right upper extremity to monitor for innominate compression.
251
Describe the Mallampati score.
The Mallampati exam assesses the oropharyngeal space. Said another way, it helps us quantify size of the tongue relative to the volume in the mouth.
Remember the mnemonic: PUSH
252
MALLAMPATI PUSH SCORE
Class I: Pillars, Uvula, Soft palate, Hard palate
Class II: __ Uvula, Soft palate, Hard palate
Class III: __ __ Soft palate, Hard palate
Class IV: __ __ __ Hard palate
253
Describe the inter-incisor gap. What is normal?
A small inter-incisor gap creates a more acute angle between the oral and glottic openings, increasing the difficulty of intubation.
254
Inter-incisor gap. Normal =
2-3 finger breaths or 4 cm
255
The patient's ability to open the mouth directly affects your ability
to align the oral, pharyngeal, and laryngeal axes
256
What is the thyromental distance, and what values suggest an increased risk of difficult intubation?
The thyromental distance helps us estimate the size of the submandibular space.
With the neck extended and mouth closed, you can measure the distance from the tip of the thyroid cartilage to the tip of the mentum.
257
Laryngoscopy may be more difficult if the TMD is
less than 6 cm (3 fingerbreadths) or greater than 9 cm.
258
What is the mandibular protrusion test, and what values suggest an increased risk of difficult intubation?
The MPT assesses the function of the temporomandibular joint. The patient is asked to sublux the jaw, and the position of the lower incisors it compared to the position of the upper incisors.
259
What is responsible for the kidney transplant rejection>?
Hyperacute- This happens quickly in the OR after clamps are released or the following hours. Complement-mediated with recipient pre-existing antibodies. The graft is usually removed to prevent severe SIRS. Rare now with better matching techniques.
Accelerated Acute- Subset of acute rejection that can be seen within the first week post-op. Cellular and/or antibody-mediated. Incidence of any rejection in first 30 days approaches 2%
260
The Mandibular Protrusion Test (MPT) assesses the function of what joint? What do you ask the patient?
temporomandibular joint. The patient is asked to sublux the jaw, and the position of the lower incisors it compared to the position of the upper incisors.
261
Class I MPT : Patient can move Lower incisors
past UI and bite the vermilion of the lip (where the lip meets the facial skin).
262
What is the vermillon of the lip?
where the lip meets the facial skin
263
Class II MPT: Patient
can move LI in line with UI.
264
Class III MPT: Patient
cannot move LI past UI (increased risk of difficult intubation).
265
What conditions impair atlanto-occipital joint mobility?
Degenerative joint disease
Rheumatic arthritis
Ankylosing spondylitis
Trauma
Surgical fixation
Klippel-Feil
Down syndrome
266
Describe the Cormack and Lehanne score. What does it help us measure?
The Cormack and Lehane grading system helps us measure the view we obtain during direct vision laryngoscopy. Obviously you can't make this determination before performing laryngoscopy.
267
List 5 risk factors for difficult mask ventilation.
BONES (Male too)
Beard
Obese (most books say BMI > 26 kg/m2)
No teeth
Elderly (age > 55 years)
Snoring
268
List 10 risk factors for difficult tracheal intubation: Mouth opening and palate description
Thyromental distance < 6 cm (<3 fingerbreadths) or > 9 cm
Neck is thick and short
Poor AO joint mobility (can’t touch chin to chest and/or can’t extend the neck)
Small mouth opening
Palate is narrow with high arch
269
List 10 risk factors for difficult tracheal intubation: Incisors
Long upper incisors
Interincisor distance < 3 cm
270
List 10 risk factors for difficult tracheal intubation: Mallampati, mandibular protrusion tests.
Mallampati class 3 or 4
Mandibular protrusion test class 3
271
List 10 risk factors for difficult tracheal intubation: submandibular space
Poor compliance of submandibular space
272
List 10 risk factors for difficult tracheal intubation: Thyromental distance, neck and joint
Thyromental distance < 6 cm (<3 fingerbreadths) or > 9 cm
Neck is thick and short
Poor AO joint mobility (can’t touch chin to chest and/or can’t extend the neck)
273
List 6 risk factors for difficult supraglottic device placement: mouth opening and airway
Limited mouth opening
Upper airway obstruction (prevents passage of device into pharynx)
274
List 6 risk factors for difficult supraglottic device placement: Airway
Poor airway compliance (requires excessive PIP)
Increased airway resistance (requires excessive PIP)
Lower airway obstruction
275
List 6 risk factors for difficult supraglottic device placement: Pharyngeal
Altered pharyngeal anatomy (prevents seal)
276
List 5 risk factors for difficult invasive airway placement.
Abnormal neck anatomy (tumor, hematoma, abscess, hx of radiation)
Limited access to cricothyroid membrane (halo, neck flexion deformity)
Laryngeal trauma
277
What kind of abnormal neck anatomy affect difficult invasive airway placement?
presence of (tumor, hematoma, abscess, hx of radiation)
278
How does obesity and short neck affect the ability to place an invasive airway ?
Obesity (can’t ID cricothyroid membrane)
Short neck (can’t ID cricothyroid membrane)
279
What is angioedema?
Angioedema is the result of increased vascular permeability that can lead to swelling of the face, tongue, and airway. Airway obstruction is an extreme concern.
280
What are two common causes of angioedema? What is the treatment for each?
Angiotensin converting inhibitors (ACEI)
Hereditary angioedema (C1 esterase deficiency)
281
What is the treatment of Angioedema when it is caused by ACEI use?
SEA
Treatment = Epinephrine, antihistamines, steroids (just like anaphylaxis)
282
What is the treatment of Angioedema when it is caused by C1 esterase deficiency ?
Treatment = C1 esterase concentrate or FFP (not epinephrine, antihistamines, or steroids)
283
What is Ludwig’s angina? What structure does if affect?
Ludwig’s angina is a bacterial infection characterized by a rapidly progressing cellulitis in the floor of the mouth. Inflammation and edema compress the submandibular, submaxillary, and sublingual spaces.
284
What is The most significant concern with Ludwig's angina?
is posterior displacement of the tongue resulting in complete, supraglottic airway obstruction.
285
Describe the Practice Guidelines for Preoperative Fasting and Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Clear Liquids
2 hours = Clear liquids
286
Describe the Practice Guidelines for Preoperative Fasting and Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Breast milk
4 hours
287
Describe the Practice Guidelines for Preoperative Fasting and Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Nonhuman milk, infant formula, solid food
6 hours = Nonhuman milk, infant formula, solid food
288
Describe the Practice Guidelines for Preoperative Fasting and Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Fried or fatty foods
8 hours = Fried or fatty foods
289
When is the best time to use an Eschmann introducer?
The Eschmann introducer is best used when a grade 3 view is obtained during laryngoscopy (grade 2 is the next best time).
290
List the 4 types of oropharyngeal airways.
Guedel
Berman
William
Ovassappian
291
The likelihood of successful intubation is unacceptably low with an Eschmann introducer when a ________is obtained.
grade 4 view
292
Which 2 oropharyngeal airwaysare best suited for fiberoptic intubation?
William
Ovassappian
293
2 other names for bougie?
Intubating stylet
Eschmann introducer
Gum elastic bougie
294
When is a nasopharyngeal airway contraindicated?
Cribriform plate injury (risk of brain injury):
LeFort II or III fracture
Basilar skull fracture
CSF rhinorrhea
Raccoon eyes
Periorbital edema
295
Previous transsphenoidal hypophysectomy : what is contraindicated?
nasopharyngeal airway
296
Other contraindications to nasopharyngeal airways
Coagulopathy (risk of epistaxis)
Previous Caldwell-Luc procedure
Nasal fracture
*Caution during pregnancy (risk of epistaxis)
297
Previous transsphenoidal hypophysectomy : what is contraindicated?
nasopharyngeal airway
298
Previous Caldwell-Luc procedure : what is contraindicated?
The Caldwell-Luc operation uses an external approach for surgical treatment of the severely diseased maxillary sinus.
299
Classify the 3 LeFORT fracturs
upper lip and below --> LeFort I
across bridge of nose and below --> LeFort II
Between eyes and below --> Lefort III
300
Contrast the maximum recommended cuff pressures for an endotracheal tube vs LMA.
ETT < 25 cm H2O
LMA < 60 cm H2O
301
Maximum ETT cuff pressure
ETT < 25 cm H2O
302
Maximum LMA cuff pressure
LMA < 60 cm H20
303
Maximum recommended peak inspiratory pressures for an LMA-Unique vs LMA-Proseal vs LMA-Supreme. (UPS )
UPS 20-30-30
LMA-Unique < 20 cm H2O
LMA-ProSeal < 30 cm H2O
LMA-Supreme < 30 cm H2O
304
What is the largest size endotracheal tube that can be passed through # 3 LMA size? Flexible endoscope
6.0 ; 5.0
305
What is the largest size endotracheal tube that can be passed through # 4 LMA size? Flexible endoscope
6.0 ; 5.0
306
What is the largest size endotracheal tube that can be passed through # 5 LMA size? Flexible endoscope
7.0 ; 5.5
307
LMA sizing and weight
Size 1 < 5kg
Size 1.5 5-10 kg
Size 2 10-20 kg
Size 2.5 20-30 kg
Size 3 30-50 kg
Size 4 50-70kg
Size 5 70-100kg
308
Cuff inflation of LMAs in mls?
4
7
10
14
20
30
40
309
How many size of LMAs?
7 (1 , 1.5, 2, 2.5, 3, 4, 5)
310
List 6 indications for the Bullard laryngoscope.
The Bullard laryngoscope is a rigid, fiberoptic device used for indirect laryngoscopy.
311
Laryngoscope use for indirect laryngoscopy
Bullard
312
Indications for Bullard laryngoscopy: STIPS
Small mouth opening (minimum = 7 mm)
Impaired cervical spine mobility
Short, thick neck
Teacher Collins syndrome
Pierre-Robin syndrome
313
Describe the proper placement of the lighted stylet
When the patient is supine, the trachea is anterior to the esophagus. Therefore, we can look at the quality of the light shining through the neck to determine if the tip of the device is located in the trachea or esophagus.
314
When the lighted stylet is in the trachea, the light has to _____What will you observe?
travel through less tissue, so you'll observe a well-defined circumscribed glow below the thyroid prominence.
315
When the lighted stylet is in the esophagus, the light has to travel through more tissue, so
you'll observe a more diffuse transillumination of the neck without the circumscribed glow.
316
Trachlite (or lighted stylet) As the light source enters the glottis opening, a
" well-defined circumscribed" glow is noticed below the thyroid prominence, and can be readily seen on the anterior neck
317
Descrine the combitude
This device contains an esophageal lumen and a tracheal lumen. The esophageal lumen has a blocked distal port and perforations at the pharyngeal level, whereas the tracheal lumen has only an open distal end.
318
With the combitude, Regardless of tracheal or esophageal placement,
the lungs may be ventilated. The usual placement of the tube is into the esophagus.
319
With the combitube, If the tube is placed in the esophagus, the what allow for ventilation?
side ports of the esophageal lumen between the pharyngeal and tracheal cuffs allow for tracheal ventilation
320
Combitude insertion is ______+ and the patient's head is _________
This blind insertion is easily accomplished,
and the patient’s head can be kept in the neutral position.
321
List 5 indications for the use of a bronchial blocker.
Bronchial blockers are indicated for patients requiring lung separation who:
Are children < 8 years of age (smallest DLT = 26F for 8 - 10 years old).
Require nasotracheal intubation.
Have a tracheostomy.
Have a single lumen ETT in place.
Require intubation after surgery, and you want to avoid changing the DLT to a single-lumen ETT at the end of the case.
322
DLTs are designed for insertion either in the
right or the left bronchus.
323
Sizing of DLTs is determined by patient
height,
324
Usual size of DLT for females
35F to 37F tubes in females
325
Usual size of DLT for Males
39F to 41F tubes in males.
326
The distance from the carinal bifurcation to the right upper lobe is, as compared with left main stem bronchus
1.5–2 cm; 4–5 cm left mainstem bronchus
327
Describe insertion of the DLT? when is the stylet removed? When is the tube rotated? to what direction?
Lubricated DLT is advanced with the distal curve concave anteriorly until the vocal cords are passed.
The stylet is usually removed after the DLT passed the vocal cords , at this point to reduce the potential of the rigid tube causing mucosal damage. The tube is then rotated 90 degrees toward the bronchus that is to be intubated. The DLT is advanced to approximately a 27-cm depth in females or a 29-cm depth
in males, or until resistance is met
328
Depth of DLT for females
27 cm
329
Depth of DLT for males
29 cm
330
For DLT, explain how much air is needed for the tracheal cuff and the bronchial cuff?
The tracheal cuff requires 5 mL to 10 mL of air, and the bronchial cuff requires 1 mL to 2 mL of air
331
Most tracheal cuff is ______ volume, _____pressure
high-volume, low pressure
cuffs,
332
Unlike tracheal cuff, The bronchial cuff holds a
small volume and can exert high pressure on the endobronchial mucosa.
333
Essential to verify placement of the DLT
Flexible fiberoptic bronchoscopy
334
When properly positioned, breath sounds should be auscultated in.
all fields of the lung corresponding to
the bronchial lumen (depending on the use of a left- or right-sided tube) when that lumen alone is ventilated. Breath sounds should be heard only in the opposite lung, when the tracheal lumen is ventilated
335
Placement of the tube should be verified when again?
should again be verified by bronchoscopy after the patient is positioned laterally because the DLT will commonly withdraw from the bronchus by 1 cm
336
The most common complication associated with a DLT is
malpositioning.
337
HPV can be expected to remain intact if volatile agents are administered at
less than 1.5 of the minimum alveolar concentration
338
One lung ventilation ; TV, RATE, FIO2 and goal SPO2,
PEEP? What if there is COPD? I:E Ratio, what if COPD ?
Ventilate:
• Tidal volume: 6–8 mL/kg
• Rate: 12–15 (permissive hypercapnia acceptable
• FiO2: 0.4–0.8; maintain SpO2 > 90%
• PEEP: 5–10 cm H2O (2.5–5 if COPD)
• I:E ratio: 1 : 2 (1 : 3 if COPD or intrinsic (auto) PEEP)
339
2 things : What should you do consider doing before initiating OLV?
Consider alveolar recruitment maneuver prior to OLV
• Assess ABG 15 minutes after OLV is initiated
340
OLV and VA
• Volatile anesthetics < 1–1.5 MAC or IV agents
341
Stepwise response to worsening hypoxemia: FIRST 3 STEPS--> ICE
•
• Increase FiO2
• Confirm tube position with fiberoptic bronchoscope
• Ensure adequacy of cardiac output
342
OLV hypoxemia --> Remedy detrimental effects caused
•
• Alter perfusion with almitrine to NDL; nitric oxide to DL
anemia or vasodilators
343
Hypoxemia during OLV: What doe you with positioning?
Reposition to lateral decubitus position if supine
344
Hypoxemia with OLV: What to do after ICE steps with ventilation: PEEP, CPAP, pressure.
• Perform alveolar recruitment maneuver to DL
• Titrate PEEP in DL
• CPAP 5–10 cm H2O to NDL
• Intermittent or continuous two-lung ventilation
• Low- or no-pressure oxygen insufflation to NDL or selected lobe of NDL
345
Perfusion fixation during OLV hypoxemia?
• Alter perfusion with almitrine to NDL; nitric oxide to DL
346
Common Tumors of the Anterior Mediastinum:
“The 4 Ts”
Thymoma
• Thyroid
• Teratoma
• “Terrible” lymphoma
347
How can the lumen of the bronchial blocker be used during OLV?
It can be used to:
Insufflate oxygen into the non-ventilated lung
Suction air from the non-ventilated lung (improves surgical exposure)
348
How can the lumen of the bronchial blocker NOT be used during OLV?It can NOT be used to:
Ventilate
Suction blood, pus, or secretions from the non-ventilated lung
349
List 2 indications for retrograde intubation.
Unstable cervical spine (most common use of RI)
Upper airway bleeding (can’t visualize glottis)
350
Most common use for retrograde intubation
Unstable cervical spine
351
Since RI requires time (~ 5-7 minutes for experienced practitioners), it is best used when
intubation has failed but ventilation is still possible.
352
Difficult airway managment; Initial intubation attempts UNSUCCESSFUL
FROM THIS POINT
ONWARD CONSIDER:
1. Calling for help
2. Returning to spontaneous
ventilation
3. Awakening the patient
353
FACE MASK VENTILATION INADEQUATE
CONSIDER/ATTEMPT
LMA
LMA ADEQUATE* LMA INADEQUATE OR NOT FEASIBLE
EMERGENCY PATHWAY
Ventilation not adequate, intubation unsuccessful
354
IF BOTH FACE MASK AND LMA VENTILATION
BECOME INADEQUATE
Call for help
Emergency noninvasive airway ventilation
355
A retrograde wire-guided intubation may be considered in situations where
intubation has failed but ventilation is possible.
356
Explain the retrograde intubation
This procedure is performed by inserting a 14- to 18-gauge IV catheter or a Cook needle through the cricothyroid membrane and directing it CEPHALAD.
After aspiration of air is confirmed, a wire or suture is then inserted through the needle and passed cephalad until it can be visualized in the POSTERIOR PHARYNX. It
is then either advanced through the mouth or retrieved using Magill forceps. The distal end of the wire is secured with a clamp at the neck to prevent the wire from being pulled into the trachea prematurely
An ETT is then directed over the wire and passed into the trachea.
357
Pros and Cons of awake extubation
Awake pros:Airway reflexes intact
Ability to maintain airway patency
Decreased risk of aspiration
Awake cons: Increased intracranial, intraocular and intraabdominal pressure, Increased coughing and CV and SNS stimulation
358
Explain the retrograde intubation
This procedure is performed by inserting a 14- to 18-gauge IV catheter or a Cook needle through the cricothyroid membrane and directing it CEPHALAD.
After aspiration of air is confirmed, a wire or suture is then inserted through the needle and passed cephalad until it can be visualized in the POSTERIOR PHARYNX. It
is then either advanced through the mouth or retrieved using Magill forceps. The distal end of the wire is secured with a clamp at the neck to prevent the wire from being pulled into the trachea prematurely
An ETT is then directed over the wire and passed into the trachea.
359
When is the best time to use an airway exchange catheter, and what can you do with it?
It is the most common device used to manage extubation of the difficult airway.
360
The airway exchange catheter is a
long, thin, flexible, hollow tube that maintains direct access to the airway following tracheal extubation.
361
What else can you do with an AEC?
EtCO2 measurement
Jet ventilation (via Luer-lock adapter)
Oxygen insufflation (via 15 mm adapter)
362
Pros and Cons of DEEP extubation
Pros : Decreased CV and SNS stimulation
Decreased Coughing
CONS: Airway reflexes ineffective
Increased risk of airway obstruction
Increased risk of aspiration.
363
How many generations of bronchial tree? What is the breakdown?
23
1-16 Conducting
17-19 Transitional
20-23 Respiratory zone
364
How many generation of bronchial tree? What is the breakdown?
23
1-16 Conducting
17-19 Transitional
20-23 Respiratory zone
365
Conducting zone starts from. what to what?
Trachea
Bronchi
Bronchioles
Terminal bronchioles
Difference between bronchi areas and bronchioles ,NO CARTILATES In BRONCHIOLES
366
Which zone contains respiratory bronchioles
Transitional zones
367
Where does the bulk of the gas exchange occurs?
respiratory zones
368
With each succeeding generation: number of airways ______, cross sectional area _______ Airflow velocity _______ and muscular layer_____
• Number of airways ↑
• Cross-sectional area ↑
• Airflow velocity ↓
• CARTILAGES ↓
• Muscular layer ↑
369
With each succeeding generation: number of airways ______, cross sectional area _______ Airflow velocity _______ and muscular layer_____
• Number of airways ↑
• Cross-sectional area ↑
• Airflow velocity ↓
• Muscular layer ↑
370
Zone that conducts gas without exchanging
Conducting
371
Some refer to the respiratory bronchioles and alveolar ducts where limited gas exchange takes place as the ______Zone because structures here function both to conduct gas and also to participate in some gas exchange.
transitionaln zone
372
Small pores in the alveoli, serve to allow collateral gas flow between alveoli and provide a mechanism of relief from gas stagnation from airway closure
Pores of Kohn,
373
Small pores in the alveoli, serve to allow collateral gas flow between alveoli and provide a mechanism of relief from gas stagnation from airway closure
known as the pores of Kohn,
374
Nagelhout total generations
There are 20 to 25 total generations before the alveoli. By the seventh generation, the diameter of bronchioles is approximately
